CLINICAL STUDY

Early Diagnosis of Diabetic Neuropathy

in Almadinah Almunawwarah

Moaz A. Mojaddidi1 Ph.D, Moutasem Aboonq1 Ph.D, Omar M AL Nozha2 SSCIM

Abdulkadir Allam2 ArBIM, Mohamed Fath EL-Bab1* Ph.D

Departments of Physiology1 and Medicine2, College of Medicine

Taibah University, Almadinah Almunawwarah, Kingdom of Saudi Arabia
Department of Physiology, College of Medicine, Suez Canal University, Ismailia, Egypt*
Abstract
Objectives
Diabetes mellitus (DM) is a major public health problem worldwide. The aim is to assess the
early detection of impaired nerve function and the risk factors associated with the
development of diabetic neuropathy.
Methods
It is a prospective descriptive study of age-matched 263 diabetic Saudi patients from the
outpatient clinic of the Diabetic Centre in King Fahd Hospital in Almadinah Almunawwarah
in Kingdom of Saudi Arabia during 2008-2009. Written informed consent was obtained from
each subject after the protocol was approved by the local ethics committee. All subjects were
diagnosed as diabetics using WHO criteria. We obtained detailed demographic data as age,
sex, special habits, height, weight and body mass index, arterial blood pressure, type and
duration of diabetes, glycosated haemoglobin (HbA 1C), lipid profile, management, family
history of hypertension, diabetes. Assessment of neuropathy by using the Diabetic
neuropathy index and diabetic neuropathy score. Asymptomatic patients who scored less
than two in clinical examination were referred to be assessed by complete neurological
examination, and nerve conduction studies. Data were calculated and compared by using
SPSS version 13.0.
Results
The type I were 39 (14.8%) and type II were 244 (85.2%) diabetic patients and the mean
duration of diabetes mellitus in all diabetic patients was 13.89 ± 8.7 years. The symptomatic
diabetic neuropathy patients were 165 (62.7%) out of 263 diabetic patients and the
asymptomatic were 98 (37.3%). The risk factors for neuropathy were old age, poor blood
sugar control, long duration of diabetes, hyperlepidemia, Body Mass Index (BMI). There
were no statistical significant differences in relation to types of diabetes mellitus. There was
positive correlation which shown by the linear regression charts between the grades of nerve
conduction defects in asymptomatic diabetic neuropathy patients and duration of diabetes,
age, BMI and HbA1C.
Conclusion
The early detection of by sub-clinical nerve conduction of diabetic patients is of a major
clinical interest that could lead to more intensive supervision of diabetic patients. Further
studies should be performed in order to confirm these findings.

Key words: Diabetic neuropathy, Diabetes mellitus risk factors, Nerve conduction studies.

Journal of Taibah University Medical Sciences 2011; 6(2): 121-131

121
 Moaz A. Mojaddidi et al
Correspondence to:
Dr. Mohamed Fath EL-Bab
Department of Physiology, College of Medicine
Taibah University,
30001 Almadinah Almunawwarah
Kingdom of Saudi Arabia
+966 4 8460008
 +966 4 8475790
 mfeb70@hotmail.com
Introduction
D iabetes mellitus (DM) is a major public
health problem worldwide. The World
Health Organization has estimated that, the
number of adults with diabetes in the
world would increase alarmingly from
135million in 1995 to 300 million in 2025 1.
One study has shown that the prevalence
of DM is about (23.7%) in 2004 in Kingdom
of Saudi Arabia and another recent study
has shown that there is a significant
increase in the prevalence which became
30% in 2011 where was 34.1% in males and
27.6% in females2-3.
Diabetic peripheral neuropathy considered
as one of the commonest complications
seen in up to 50% of affected patients with
type 1 and type 2 DM leading to substantial
morbidity, discomfort and associated with
increased mortality according to its
severity4,5.
Nerve conduction studies, primarily nerve
conduction velocities are considered one of
the most sensitive indices of the severity of
neuropathy and were used to localize
lesions and to describe the type and
severity of the pathophysiological process,
including alterations in function that are
not recognized clinically 6.
The aim of this research was to study the
prevalence of asymptomatic diabetic
neuropathy in Almadinah Almunawwarah
in the Kingdom of Saudi Arabia as an
example of the western district and find
out the prevalence of the associated risk
factors with symptomatic and
asymptomatic diabetic neuropathy.
122
Material and Methods
It is a prospective descriptive study, the
protocol was approved by the local ethics
committee and written informed consent
was obtained from each patient who
attended the outpatient clinic of the
Diabetic Patients Medical Centre in king
Fahad hospital in Almadinah
Almunawwarah in Kingdom of Saudi
Arabia in the academic year of 2008/2009.
All subjects diagnosed as diabetics using
international standard criteria 7-10.
We obtained detailed demographic data as
age, sex, special habits, height, weight and
body mass index, arterial blood pressure,
type and duration of diabetes, glucosated
haemoglobin (HbA 1C), lipids profile,
management, family history of
hypertension, diabetes. Neuropathy was
assessed by using the Michigan
Neuropathy program which includes two
steps; the Diabetic Neuropathy Index (DNI)
and the Diabetic Neuropathy Score (DNS).
Patients who scored less than 2 on routine
clinical examination and were
asymptomatic were referred to be assessed
by complete neurological examination
done by neurologist, and nerve conduction
studies (Appendices 1 and 2).
The electrophysiological tests were
performed by the same neurophysiologist,
and he was blinded to the clinical
information of the subjects. The procedures
were explained for the patient, and all
nerve-conduction tests were performed in
the same room with a comfort temperature
of 22°C to 25°C using standard protocol11.
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 Early diagnosis of diabetic neuropathy in Almadinah Almunawwarah
We used The XL Calibre Ltd EMG system to
perform the recording. The optimal
recording amplifier frequency range of 50
Hz. to 10 KHz and a standard sensitively of
100 to 500 UV. Nerve conduction velocity
was assessed in Median, ulnar, peroneal,
sural nerve and posterior tibial nerves
Motor nerve conduction velocity was
measured on the left forearm segment of the
median nerve (thenar muscle), and the left
peroneal nerve (extensor digitorum brevis
and tibial anterior muscle)12-14. Minimal F-
wave latencies were acquired from the same
recording and distal stimulation points,
from at least eight tracings. F-wave
conduction velocity was calculated as
described elsewhere data were collected,
calculated and statistical analyses were
carried out by using Statistical Package for
Social Sciences (SPSS version XIII, Inc.,
Chicago, Illinois). Results were considered
statistically significant at P-value less than
or equal to 0.0518-19.
Results
The 263 diabetic Saudi patients distributed
as follows: type I was 39 (14.8) and type II
was 224 (85.2%) and the mean duration of
diabetes mellitus was 13.89 ± 8.7 years. The
distribution of the patients according to
their gender and type of diabetes were 15
(51.7%) males in type I and 14 (47.3%)
females, and type II they were 107 (45.7%)
males and 127 (54.3%) females. The positive
family history of diabetes was 66.9% and for
the hypertension was 33.5%. The non-
smokers representing 86.7%.
There were 122 males and 141 females’ with
male to female ratio of 1:1.15, aged 20-70
years (51.79 ± 10.88 years). The patients with
neuropathy were 155 (58.9%) and 108
(41.1%) diabetic patients were free from
signs and symptoms of neuropathy as
assessed initially by the DNI. Further
assessment by the DNS and the neurological
examinations added 10 more patients
(3.8%). So, patients became 165 (62.7%) and
those clinically free 98 (37.3%). The positive
DN patients diagnosed by electrophysio-
123
logical studies were 43 (16.4.) The results
show that positive family history of diabetes
was seen in 115 patient (69.6%) and 54
(55.1%), the smokers number and
percentage were 13 (0.07%) and 3 (0.03%)
while type II represented as 146 (88.4%) and
78 (79.5) in the symptomatic and
asymptomatic DN patients respectively. The
symptomatic DN diabetic patients mean
BMI was 33.42 ± 5.68 and that of
asymptomatic was 33.45 ± 6.88 which makes
them more susceptible to chronic disease
e.g. hypertension and diabetes mellitus
complications. The mean systolic blood
pressure among symptomatic and the
asymptomatic DN patients were (140.19 ±
18.30 and 138.77 ± 21.21mmHg) and the
mean diastolic were respectively (83.30 ±
11.37 and 81.22 ± 9.47 mmHg). Hypertensive
family history was 61 patients (36.9%)
positive in symptomatic and 28 (28.5%) in
asymptomatic patient.
On the other hand, we found that HbA1C
was higher in symptomatic DN patients
(10.06 ±1.91) symptomatic to (8.58 ±1.41) in a
symptomatic patients indicated worst
glucose control in the first group. We also
revealed that there were more hyper-
lepidemic symptomatic patients 47 (28.4)
and has asymptomatic which were 29 (29.5),
where the total cholesterol, triglycerides and
the LDL were higher than the normal values
in both groups (Table 1).
The results show that the mean risk score for
the females (2.88± 4.18) was higher than the
males (1.77 ± 4.30) with no statistical
differences (Figure 1).
The number of patients, who were clinically
asymptomatic and diagnosed electro-
physiologically, was as mild, moderate, and
severe nerve conductions defect as shown in
(Figure 2).
There was a positive correlation shown by
the linear regression charts between the
grades of asymptomatic patients and the
diabetes mellitus duration, glycosated
haemoglobin, age and BMI of the nerve
conduction defects among clinically free
diabetic neuropathy (Figure 3).-----------------
J T U Med Sc 2011; 6(2)
 Moaz A. Mojaddidi et al

Table 1: comparison between the diabetic neuropathy patients and the asymptomatic patients
according to different variables.

Asymptomatic diabetic Symptomatic diabetic

Features neuropathy neuropathy
N (%) 98 N (%) 165
Age 49.84 ± 11.85 52.90 ± 10.21
Males: females ratio 1: 1.1 1:1.22
Dm duration 12.05 ± 7.43 14.32 ± 8.39
Type ii 78 (79.5) 146 (88.4)
Family history of
28 (28.5) 61 (36.9)
hypertension
Family history of dm 54 (55.1) 115 (69.6)
Smokers (non-smokers) 3 (0.03) 13 (0.07)
Body mass index 33.45 ± 6.88 33.42 ± 5.68
Systolic blood pressure 138.77 ± 21.21 140.19 ± 18.30
Diastolic blood pressure 81.22 ± 9.47 83.30 ± 11.37
Glucosated haemoglobin 8.58 ± 1.41 10.06 ± 1.91
Hyperlepidemia 29 (29.5) 47 (28.4)
Total cholesterol 5.36 ± 1.04 5.68 ± 1.30
Triglyceride 2.24 ± 0.90 2.78 ± 1.17
Low density lipoprotein 3.25 ± 0.77 3.27 ± 0.67

Figure 1: The box plot chart shows the female and the male diabetic patients mean values risk factors score.

124
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 Early diagnosis of diabetic neuropathy in Almadinah Almunawwarah

Figure 2: The column with a cylindrical shape charts shows the grades of nerve conduction defects in
clinically free diabetic neuropathy (asymptomatic) patients.

A- the diabetes mellitus duration B- the glucosated haemoglobin

Diabetes Mellitus Duration (years)

40.00 14.00
Glucosated Haemoglobin

30.00 12.00

10.00
20.00

8.00
10.00 R Sq Linear = 0.44 R Sq Linear = 0.995
6.00
0.00

-10 0 10 20 -4 -2 0 2 4 6
Regression Deleted (Press) Residual Regression Deleted (Press) Residual

C- the age in years D- body mass index (bmi)

70.00 50.00

60.00 45.00
Body Mass Index (BMI)

40.00
Age (years)

50.00
35.00
40.00
30.00
R Sq Linear = 0.924
30.00 R Sq Linear = 0.981
25.00

20.00 20.00

-40 -30 -20 -10 0 10 20 -10 -5 0 5 10 15

Regression Deleted (Press) Residual Regression Deleted (Press) Residual

Figure 3: The linear regression charts showing correlation between different risk factors (A- the diabetes
mellitus duration, B- the glucosated haemoglobin, C- the age, D- the BMI) and the grades of the nerve
conduction defects among clinically free diabetic neuropathy (asymptomatic) patients.

125
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 Moaz A. Mojaddidi et al
Discussion
Our study has endeavoured to provide a
part of the picture of the sub clinical pattern
of diabetic neuropathy in DM from
Kingdom of Saudi Arabia as a developing
area in the Middle East. Polyneuropathy
prevalence varies greatly depending on the
clinical and the electrophysiological
diagnostic criteria of ADA9-10. The
electrophysiological measu-res include the
studies of sensory and motor nerve
conduction, F-wave recordings, and surface
electrodes electromyography. In Kingdom
of Saudi Arabia, the prevalence of diabetic
neuropathy was observed to be 35.9% after
screening 1000 diabetics17.
From our results we found that the diabetic
neuropathy is mainly in sensory nerves
more than motor nerves particularly in the
lower limbs, which affect the small caliber
nerves as sural nerve, and the abnormalities
were in the nerve conduction velocity,
latencies, and F-wave studies results, rather
than in the amplitudes, as well it was more
in type II diabetes mellitus Patients
The early diagnosis of diabetic poly neuro-
pathy (DPN) is important in that it allows
for immediate interventions, which decrease
both mortality and morbidity a rise in the
prevalence of the commonly associated
complications, namely the various forms of
diabetic neuropathy, is therefore
anticipated18-22. The present study focused
on a group of type II and type I diabetic
patients who were free from neurologically
symptoms. Diagnosis of DPN on clinical
ground alone is not accurate and there is
difficulty in detecting a small alteration of
neuropathy23-24.
Therefore, as a surrogate measure, nerve
conduction study (NCS) is widely used as
an evaluation of DPN. In general, it has been
accepted that the ideal diagnosis of DPN is
made by both the compatible clinical
findings and the related electrophysiological
changes25.
Diabetes is the leading cause of neuropathy
in the Western world, and neuropathy is the
most common complication and greatest
source of morbidity and mortality in
diabetes patients26. It is estimated from a
126
comprehensive collection of epidemiologic
studies that the prevalence of neuropathy in
diabetes patients is approximately 30% in
hospital patients and 20% in community
patients22. The overall annual incidence of
neuropathy was < 2%27.
The following factors increase the
susceptibility to nerve damage: Poor blood
sugar control, Length of time the patient has
diabetes, Age, Sex, High cholesterol,
Smoking28.
The American Diabetes Association
recommends that glycosylated haemoglobin
(HbA1c) should be less than 7%9-10. Most
previous studies, which reported HbA1c
correlation with polyneuropathy, used
higher HbA1c cut points and focused on
neurologically symptomatic patients.
We showed in our results that diabetic
patients had poor glucose control as
indicated by high Haemoglobin A1c as it was
10.06 ± 1.91 in symptomatic DN patients and
8.58 ± 1.41 in asymptomatic. Hyperinsuline-
mia and hyperglycaemia might affect
through their co-morbidities as hyper-
tension, dyslipidemia, and central body fat
distribution29-30.
Hypertension was found in 57.8% of our
diabetic patients with no statistically
significant difference between males and
females. The mean age of diabetic patients
was significantly higher in hypertensive
than non-hypertensive. There were only
14.2% of hypertensive diabetic patients in
whom blood pressure was controlled. Poor
control was significantly associated with
obesity, and a higher rate of complications,
so our results are in agreement with what
was reported that the blood pressure control
correlated positively and significantly with
the age of patients, and negatively with
duration of diabetes and hypertension as
observed regarding the anthropometrical
variables, the BMI values obtained about the
excessive weight in all groups' patients are
similar to those found in a multi-centric
study carried out with more than 2,500 type
II DM patients in 12 cities of different
Brazilian regions31-32. The high prevalence of
overweight diabetic patients has been
appointed by epidemiological research in
the South and Southeast of Kingdom of
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 Early diagnosis of diabetic neuropathy in Almadinah Almunawwarah
Saudi Arabia, estimating that between 80
and 90% of individuals with type II DM are
obese or overweight33.
However, despite awareness about the
importance of excessive body weight for
morbidity and mortality of patients with
type II DM, the control of this variable in
diabetic populations has rarely been
emphasized in most studies. In addition, the
approach to this problem in basic health
care has been neglected, since
recommendations on the control of these
variables exist in most services, but are not
accompanied by resources that can
adequately support individuals in an
effective change that results in weight loss34.
Laboratory data indicate high prevalence of
dyslipidemia in our patients, similar to that
found in a survey with type II DM patients,
performed in Rio Grande do Sul 67%
presented total cholesterol over 200mg/dL;
65% triglycerides > 150 mg/dL and 47% low
HDL cholesterol >50 mg/dL34. Peripheral
neuropathy is a common clinical problem
confronting the practicing neurologist.
Several groups have demonstrated a 30% to
45% prevalence of impaired glucose
tolerance (IGT) in patients with otherwise
idiopathic neuropathy35. In concordance
with the results of the DCCT, UKPDS and
Booya et al, our study shows the same risk
factors published in different reports such as
poor blood sugar control, the duration of
having diabetes, the age, the high level of
low-density lipoprotein (LDL) cholesterol
which damaged the small blood vessels that
nourish the nerves, and smoking where they
enhance the atherosclerotic effect and
reduce the blood flow to the legs and feet
ending in damage of the peripheral
nerves36-38. Other researchers reported that
the diabetic neuropathy was significantly
associated with age, duration of disease,
negative association with arterial blood
pressure, smoking status, low HDL
cholesterol level, high triglyceride level, BMI
and HbA1c 38-42.
The diabetic individuals were, on average,
more obese than the control group, with
higher values for body mass index (BMI),
Waist Hip Ratio and percentage body fat.
The mean systolic and diastolic blood
127
pressures were higher in the diabetic group
than in the control group, as was the serum
triglyceride43.
Our results showed no statistical significant
differences and there was no correlation
between the diabetes mellitus type I and
type II and the risk factors score which
indicates that the risk factor effects were
equal in both types of diabetes mellitus.
Our study is in agreement with Tesfaye et
al, and DCCT findings, that the mean
glycosylated haemoglobin had a strong
correlation with neuropathy35,44.
Clinical spectrum of diabetic neuropathy is
variable; it may be asymptomatic, but once
established as neuropathy, it is irreversible
and may finally be disabling. We
determined the nerve conduction defects in
asymptomatic diabetic patients.
Our study results are in agreement with the
results of EL-Salem et al which showed a
correlation between elevated glycosylated
hemoglobin and subclinical neuropathy in
neurologically asymptomatic diabetic
patients and the authors recommended that
therapies for diabetic neuropathy should
target the early stages of the disease29.
Karsidag et al reported that there is a
correlation between HbA1c levels and nerve
conduction velocity in posterior tibial and
peroneal nerves. However, upper extremity
nerve conduction dysfunction was not
correlated with HbA1c value45. Neither the
duration of disease nor the age of the subject
correlated with the nerve dysfunction, and
that group reported that the percentages of
abnormal electrophysiological parameters in
different motor and sensory nerves were
86.7% in sural nerve, 83.3% in peroneal
motor nerve, 73.3% in posterior tibial motor
nerve, 66.7% in median motor nerve, 63.3%
in ulnar motor nerve, 60% in median
sensory nerve, and 46.7% in ulnar sensory
nerve. While distal motor latency, F
conduction time, and minimum F latency
were the most frequent abnormal
parameters in the upper extremity
electrophysiological study; conduction
velocity, minimum and mean F latencies, F
conduction time were the most frequent
abnormal parameters in the lower extremity
and in all sensory nerve conduction studies,
J T U Med Sc 2011; 6(2)
 Moaz A. Mojaddidi et al
the most frequent abnormal parameter was
the onset latency.
Baba M, and Ozaki I, 2001 the prevalence of
subclinical diabetic polyneuropathy in the
United Arab of Emirates UAE, and they
found close association between neuro-
logical deficit score and abnormalities in
NCS46. Among various parameter of
systemic nerve conduction studies in
subclinical patients, prolonged F-wave
latency seems the commonest abnormality
suggesting morphological changes in
subclinical diabetic nerves.
Conclusion
In conclusion, neuropathy was diagnosed in
79% of our diabetic patients by a
combination of clinical findings and
electrophysiological studies (EPS). This is a
worrying prevalence, especially as it was
picked up in 44% of asymptomatic patients
by (EPS). This should be emphasized in the
care of our diabetics. Further studies needed
to confirm these findings.
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Appendix 1: Physical Assessment (To be completed by health professional).

APPEARANCE OF FEET RIGHT LEFT

Normal Yes (0), If no, check all that apply: Yes (0), If no, check all that apply:
Deformities Yes (0) No (1) Yes (0) No (1)
Dry skin, callus Yes (0) No (1) Yes (0) No (1)
Infection Yes (0) No (1) Yes (0) No (1)
Fissure Yes (0) No (1) Yes (0) No (1)
Ulceration Present (0) Absent (1) Present (0) Absent (1)
Other - specify:
Present Reinforce Present Reinforce
Ankle Reflexes Absent (1) Absent (1)
(0) ment (0.5) (0) ment (0.5)
Vibration perception at Present Decreased Present Decreased
Absent (1) Absent (1)
great toe (0) (0.5) (0) (0.5)
Normal Reduced Normal Reduced
Monofilament Absent (1) Absent (1)
(0) (0.5) (0) (0.5)
Total Score /10 Points

Appendix 2: Michigan Neuropathy Screening Instrument.

History (To be completed by the person with diabetes) Yes No

1. Are you legs and/or feet numb? 1 2

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 Early diagnosis of diabetic neuropathy in Almadinah Almunawwarah

2. Do you ever have any burning pain in your legs and/or feet? 1 2
3. Are your feet too sensitive to touch? 1 2
4. Do you get muscle cramps in your legs and/or feet? 1 2
5. Do you ever have any prickling feelings in your legs or feet? 1 2
6. Does it hurt when the bed covers touch your skin? 1 2
When you get into the tub or shower, are you able to tell the hot water from the
7. 1 2
cold water?
8. Have you ever had an open sore on your foot? 1 2
9. Has your doctor ever told you that you have diabetic neuropathy? 1 2
10. Do you feel weak all over most of the time? 1 2
11. Are your symptoms worse at night? 1 2
12. Do your legs hurt when you walk? 1 2
13. Are you able to sense your feet when you walk? 1 2
14. Is the skin on your feet so dry that it cracks open? 1 2
15. Have you ever had an amputation? 1 2
Total score:

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